2.0 Analysis 2.1 Weather The weather conditions prevailing in the area throughout the day warranted postponing the cruise to a more suitable time. Foggy periods occur frequently along the coast during the summer and vessels must therefore be equipped with accurate navigational instruments to avoid disorientation. 2.2 Inspection A vessel not over five gross tons that carries not more than 12 passengers is not required to undergo regulatory inspections by the CCG Ship Safety Branch. The vessel must, however, comply with the requirements of the Small Vessel Regulations. In July 1993, during a CCG Ship Safety Branch inspection of such vessels carrying not more than 12 passengers, 10 companies were found operating 18 boats that did not comply with the Small Vessel Regulations. The TAN 1 and the TAN 2 were among the boats that did not comply with the Small Vessel Regulations, and the owner was issued a notice to comply with the requirements within three weeks. At the time of the occurrence, on 11 August 1993, both boats still did not comply with the requirements. On 13 August 1993, as a result of this occurrence, a detaining order was issued by the CCG Ship Safety Branch against both boats until they complied with the regulations. 2.3 Passenger Safety Whale-watching cruises are usually conducted during the summer months, because these sea mammals are not in the area for very long. The owners of these boats therefore carry on their operations on a seasonal basis. The regulations covering passenger vessels of more than five gross tons do not apply to passenger-carrying vessels not over five gross tons that carry not more than 12 passengers. Passenger vessels of more than five gross tons are required to be inspected by the CCG Ship Safety Branch and to have duly certificated officers, which is not the case for small passenger-carrying vessels not over five gross tons that carry not more than 12 passengers. No training or certification is required to operate such a vessel. 2.4 Small Vessel Regulations, Ship Station Radio Regulations and Radio Operators' Certificate Regulations Enforcement of the Small Vessel Regulations falls under the jurisdiction of the Sret du Qubec (SQ), the Royal Canadian Mounted Police (RCMP), the Ports Canada police and municipal police forces. Inspections of pleasure craft only are carried out from time to time for prevention purposes, and the MRSC courtesy inspections are carried out on these craft as well. As a result, vessels not over five gross tons that carry not more than 12 passengers are not regularly inspected and there is less follow-up of such vessels. However, Ship Safety Branch surveyors make sporadic visits to these vessels. Although the Radio Operators' Certificate Regulations require that VHF radiotelephone operators hold a certificate, neither of the two operators held such a certificate at the time of the occurrence. Although a radio was fitted, Ship Safety Branch surveyors found that the radio and its installation did not comply with the Ship Station Radio Regulations. 2.5 Reporting of the Number of Passengers on Sight-seeing Boats The regulations pertaining to Vessel Traffic Services Zones apply to all vessels 20 m or more in length, but they contain no provisions about reporting the number of passengers on board. VTC Les Escoumins has counted six sight-seeing boats over 20 m in length in the area of the occurrence that require a departure clearance and 26 others under 20 m that do not. Some do report the number of passengers on board, and others do not. In the event of a marine occurrence, the number of passengers on board a vessel is an important consideration for Search and Rescue services and the Canadian Armed Forces. Indeed, the number of persons on board a vessel involved in an occurrence determines the marine and air resources required to effect a rescue. There was some delay in dispatching the CCGS LE ROUGE and the ABRAHAM MARTIN to the scene because the number of persons on board the TAN 1 was unknown. Furthermore, the boat had not reported her departure to the VTC, and she was not required to do so by regulation. 2.6 Certificate of Competency The Canada Shipping Act exempts vessels not over five tons gross that carry not more than 12 passengers, from the requirement to have a certificated officer. In addition, there is no requirement for the operator of such a vessel to attend a navigation course. There is reason to believe that a lack of training was involved in this occurrence. The cruises were undertaken even though the weather was foggy and the safety equipment was inadequate. Disoriented because of the fog, the operator was unable to follow the compass because it was out of adjustment or because the operator did not know how to use it. 3.0 Conclusions 3.1 Findings The two boats undertook the cruises, in the foggy conditions, although they were not equipped for instrument navigation. Communication between the Vessel Traffic Centre (VTC) and the TAN 1 was cut off when the very high frequency (VHF) radio on the TAN 1 failed due to depleted batteries. The absence of a radar reflector and the failure of the VHF radio hampered the search and rescue operations in the prevailing restricted visibility. The TAN 1 steered by dead reckoning toward the Grande Batture at Les Escoumins and grounded on a large rock. The operator of the boat became disoriented in the fog and was unable to follow the compass. The operators of both boats did not hold a radio operator's certificate nor a certificate of competency and they had not been trained for instrument navigation. Vessels not over five gross tons that carry not more than 12 passengers are not required to be inspected by the Canadian Coast Guard (CCG) Ship Safety Branch. The operator of the boat did not report to the VTC upon departure, nor was he required to do so by regulation. The VTC had not been informed of the number of persons on board the TAN 1. 3.2 Causes The TAN 1 departed on a cruise to watch sea mammals in restricted visibility with inadequate safety equipment and without having on board the navigational instruments necessary for a safe cruise. 4.0 Safety Action 4.1 Action Taken 4.1.1 Navigation Equipment As a result of this occurrence and of the detaining order issued by the Canadian Coast Guard (CCG) Ship Safety Branch, the owner made the required improvements to the navigation equipment including the fitting of a commercial radar reflector, the installation of a watertight very high frequency (VHF) radio set equipped for a radio watch on the distress channel and with a battery charger connected to the motor, and he also added more visible navigation lights. 4.1.2 Radio Certificates The owner now keeps the radio inspection certificates of his boats and the restricted radio operator's certificates of his operators up to date. 4.1.3 Sail Plans and Safety Briefings In 1994, following several marine occurrences involving charter vessels, the Board recommended that: The Department of Transport encourage charter boat operators to establish sailing plans and to conduct passenger safety briefings before getting under way. The CCG subsequently published Ship Safety Bulletin No. 4/95, entitled Recommended Safety Communication Measures for Small Craft. This bulletin directed to operators of all small craft explains the benefits of sail plans and the procedures to file a sail plan with the CCG. It also encourages boat operators to give safety briefings and to demonstrate what measures to take in an emergency. 4.2 Action Required 4.2.1 Operator Certification and Training The Canada Shipping Act (CSA) does not require the operators of vessels not over five gross tons that carry not more than 12 passengers to hold a certificate of competency. In order to meet the ever-increasing demand for sight-seeing tours on the St. Lawrence River, numerous operators with no formal marine training operate inflatable boats and small home-built craft not over five gross tons without their boats being inspected or having to demonstrate their own navigational skills. The majority of small boat operators have very limited training in navigation and marine emergency duties, and this lack of training and knowledge of safety measures can have serious consequences in an emergency situation. Furthermore, given the large number of tourists and the short summer season, owners of small boats sometimes depart on a voyage in spite of adverse weather conditions. Such a practice is potentially hazardous given the conditions encountered in the vicinity of Les Escoumins and at the mouth of the Saguenay River: strong currents, reduced visibility, and numerous ocean-going and coastal vessels converging on the pilot station which increases the risk of collisions. In this occurrence, the whale-watching cruise was undertaken in spite of the fog. These small boats occasionally do get lost in fog or experience a mechanical failure which requires CCG assistance. For example, on 09 August 1994, the CROISIRE EXPRESS I ran aground with 13 persons on board because of a navigational error. On 25 June 1994, the TAN 2 had to be towed after she experienced a mechanical failure while carrying 15 persons. On 12 September 1993, one month after this occurrence, the TAN 1 experienced a mechanical failure and lost power. Waves broke over the stern, and the boat capsized. All 12 passengers and the operator were thrown into the icy waters of the river, but they were rescued by other sight-seeing boats in the area (TSB occurrence No. M93L0004). Well aware of the shortcomings in their training, some owners' associations have approached the CCG and asked that training courses be developed to meet the specific needs of small sight-seeing boat operators. As sight-seeing boats are increasingly carrying fare-paying passengers, the Board believes that it is important for small boat operators to have formal marine training. The Board is concerned that there is currently no training required to operate small passenger-carrying sight-seeing boats. Therefore, the Board recommends that: The Department of Transport develop training standards and certification requirements for the operators of small sight-seeing boats that carry fare-paying passengers. 4.2.2 Communications The Radio Operators' Certificate Regulations require radio operators to hold a Restricted Radiotelephone Operator's Certificate, but neither the operator of the TAN 1 nor the operator of the TAN 2 held such a certificate. Furthermore, as the Ship Station Radio Regulations do not apply to vessels less than 20 m in length, neither boat was required to report to the Vessel Traffic Centre (VTC) the number of persons on board. Each year during the summer months, an average of 800 passengers daily take sight-seeing cruises of one hour or more on small boats like the TAN 1. In this occurrence, because the portable VHF radio on the TAN 1 failed due to depleted batteries, the VTC was unable to monitor the situation and did not know exactly how many persons were in danger. However, to carry out a timely and successful search and rescue operation, it is critical that shore staff and/or Search and Rescue (SAR) personnel have accurate information as to the number of lives at risk aboard vessels involved in an occurrence. Further, the Board is concerned that passengers on these small sight-seeing boats may unnecessarily be exposed to risks in that such boats are not required to be fitted with the radio equipment necessary for effective communication in distress or emergency situations. Therefore, the Board recommends that: The Department of Transport amend the regulations to require sight-seeing boats that carry fare-paying passengers to be fitted with adequate radio equipment and to report to the VTC, before departure, the number of persons on board. M96-02 Assessment/Reassessment Rating: Satisfactory in Part 4.2.3 Inspection and Monitoring In July 1993, the CCG carried out courtesy inspections, and 18 sight-seeing boats were found that did not comply with the Small Vessel Regulations. The most common deficiencies noted were radio station licences; radiotelephone operator's certificates; lifejackets; navigation lights; radar reflectors; distress signals; lifebuoys; fire extinguishers; anchors; and bilge pumps. At that time, the owners of the boats involved were issued a notice to comply with the regulatory requirements. Following this occurrence, the CCG issued detaining orders for the TAN 1 and the TAN 2. The Board is concerned for the safety of passengers carried on such sight-seeing vessels without adequate safety equipment on board. The Board notes that the CCG does not have an inspection and prevention program in place for small commercial vessels not over five gross tons that carry not more than 12 passengers, but that SAR personnel currently carry out courtesy inspections of pleasure craft. The Board is also concerned that, although it is their mandate to do so according to the Small Vessel Regulations, police forces are unable to adequately monitor these boats because of limited resources. Therefore, the Board recommends that: The Department of Transport and the Department of Fisheries and Oceans, in cooperation with police forces and SAR personnel, explore means of improving the monitoring and inspection of small passenger-carrying commercial vessels.